The document provides information on the assessment and management of head and spinal trauma. It outlines the ABC approach for head trauma and emphasizes preventing secondary brain injury. It describes evaluating the Glasgow Coma Scale and pupillary responses. For spinal trauma, it stresses immobilization and protecting the spine during transport. Key factors include preventing further neurological injury and addressing airway, breathing, circulation issues.

2. HEAD & SPINAL TRAUMA

6. Head Trauma Objectives To understand the structured approach to the patient with head trauma To learn how to identify serious and life-threatening head injuries

7. Head Trauma Accounts for 1/3-1/2 of trauma deaths Good outcomes are possible without CT scans and neurosurgeons Aim to avoid any further injury to the brain Hypoxia and hypotension double mortality

8. Head Trauma Approach A irway B reathing C irculation

9. Head Trauma Physiology CPP = MAP - ICP CPP = cerebral perfusion pressure MAP = mean arterial pressure ICP = intracranial pressure

10. Cerebral Blood Flow Depends on: CPP (MAP-ICP) PaCO 2 PaO 2 Local metabolites

11. Head Trauma Pathophysiology Primary Injury - occurs at time of injury Secondary Injury - occurs after injury - may be preventable

12. HEAD TRAUMA Primary injury Diffuse axonal injury acceleration deceleration Cerebral contusion Penetrating injury

13. HEAD TRAUMA Secondary injury Hypoxia Hypoperfusion (  ICP,  MAP) Hypoglycaemia Hyperthermia (fever) Seizures

14. Head Trauma Initial assessment A irway (+ C-spine) B reathing C irculation D isability (AVPU, pupils) E xposure

15. Head Trauma Examination Glasgow Coma Score Pupils Corneal reflex Eye position Fundi

16. Head Trauma Examination Tympanic membrane Scalp and skull Respiratory Pattern Muscle tone Posture Tendon reflexes

17. Head Trauma Glasgow Coma Score (GCS) Grades severity of head injury Score out of 15 Subject to inter-observer variation Trend of GCS over time very useful Important to describe responses also

18. Head Trauma GCS Eye opening Open spontaneously 4 Open to command 3 Open to pain 2 None 1

19. Head Trauma GCS Best Verbal Response Oriented 5 Confused 4 Inappropriate words 3 Inappropriate sounds 2 None 1

20. Head Trauma GCS Best Motor Response Obeys command 6 Localises to pain 5 Withdraws to pain 4 Abnormal flexion 3 Extensor response 2 None 1

21. Head Trauma Severity of Head Injury Severe GCS <8 Moderate GCS 9-12 Minor GCS 13-15

22. Head Trauma Pupillary signs Size Reactivity Equality

23. Head Trauma Pupillary responses Fixed, dilated, unresponsive Severe hypoxia Hypothermia Seizures

24. Head Trauma Pupillary responses Unilateral, dilated, unresponsive Expanding lesion on same side Tentorial herniation Seizures

25. Head Trauma Acute extradural Acute subdural potentially life-threatening immediate recognition essential require burr-hole decompression

26. Head Trauma Acute extradural LOC  lucid interval  deterioration middle meningeal artery bleed overlying skull fracture contralateral hemiparesis fixed pupil on side of injury

27. Head Trauma Acute subdural Tearing of bridging vein between cortex and dura Severe contusion of underlying brain Usually no lucid interval Worse prognosis than extradural haematoma

28. Head Trauma Other injuries Base-of-skull fractures Cerebral concussion Depressed skull fracture Intracerebral haematoma Usually do not require neurosurgery

29. Airway Breathing (ventilation) Circulation + Avoid  ICP Head Trauma Management Aim to prevent secondary injury

30. Head Trauma Severe (GCS<8) Intubate Normal CO 2 Treat hypotension with fluid Sedation +/- paralysis

31. Head Trauma Severe (GCS<8) Nurse head up 20 o Prevent hyperthermia Complete secondary survey Reassess frequently

32. Head Trauma Beware Deteriorating conscious state Penetrating injury Focal neurological signs - unequal, dilated pupils - seizures - posturing

33. Head Trauma ?

34. Head Trauma Summary ABCs Prevent secondary injury Isolated head trauma doesn’t cause hypotension Look for other injuries Deterioration  reassess

35. Spinal Trauma

38. Spinal Trauma Objectives To understand the structured approach to the patient with spinal trauma To learn how to identify serious and life-threatening spinal injuries

39. Spinal Trauma Primary survey A irway + Cervical spine Breathing Circulation Disability Exposure

40. Spinal Trauma Secondary survey Immobilise - stiff neck collar - sandbags + tapes - in-line immobilisation Examine in neutral position Log-roll to examine back

41. Spinal Trauma Secondary survey Local tenderness Swelling Deformity and stepping

42. Spinal Trauma Assessment of level Motor response Sensory response especially sacral sparing Reflexes Autonomic function - bowel control - bladder control

43. Spinal Trauma High risk for C-spine Head injury Paradoxical (diaphragmatic) breathing Flaccid limbs No reflexes (check rectal sphincter) Hypotension (+bradycardia)

44. Spinal Trauma Transport Never transport in sitting or prone position STABILISE SPINE PRIOR TO MOVEMENT Log roll for transfer

45. If spine is protected, its further examination and evaluation can be safely deferred until other life threatening emergencies are dealt with.

46. How spine can be protected? Manual in line traction Roll of newspapers Collars KED/ RED Spinal board Four point fixation of cervical spine Log roll Spinal lift Scoop stretcher

47. Cervical Collars

48. Spinal Board

50. LOG ROLLING LOG ROLL AND PROTECTION

52. Spinal Lift & Log-roll

55. Primary Survey and Resuscitation A irway with cervical spine control Assess – Clear – No head tilt – Definitive Airway B reathing: Oxygenation – Ventilation High spinal injury and paralysis of respiratory mls C irculation with haemorrhage control Neurgenic shock – bradycarida + hypotension don’t overload, use inotropes D isability: Brief neurologic examination Paraplegia, tetraplegia, radiculopathy E xposure and environmental control Logroll, undress, examine spine, check bulbocavernuous reflex

56. Secondary Survey and Neurological Assessment AMPLE HISTORY ATTITUDE GCS AND PUPILS SENSORY EXAMINATION MOTOR EXAMINATION REFLEXES A LLERGIES M EDICATIONS P AST HISTORY/ PREGNANCY L AST MEAL E NVIRONMENT/ EVENTS – MECHANISM OF SPINAL INJURY

57. HOW TO RULE OUT SPINAL INJURY?

58. NO NECK PAIN NO NEUROLOGICAL DEFICIT Unlikely to have acute c/spine injury Remove collar Palpate spine, if non-tender Ask to move neck from side to side Ask to flex and extend neck Active movements normal = spine is cleared  No x-rays needed

59. NECK PAIN IS PRESENT NO NEUROLOGICAL DEFICIT X-rays – cross table lat/ AP/ open mouth Flexion/extension views if above are normal CT if still in doubt

60. NEUROLOGICAL DEFICIT (PARA OR TETRAPLEGIA) Presumptive evidence of spinal injury Keep spine protected Appropriate x-rays Take these patients off spinal board within 2hrs otherwise high chance of pressure sores

61. COMATOSED OR ALTERED LEVEL OF CONSCIOUSNESS OR TOO YOUNG TO DESCRIBE THEIR SYMPTOMS X-rays – cross table lat/ AP/ open mouth (if possible) Flexion/extension views if above are normal CT if still in doubt Review by Neuro/Ortho/Spinal surgeon

62. Incidence Stability 90% are stable injuries and 10% are unstable Neurological deficit 75% unstable injuries have neurological deficit Spinal Cord Injury (< 5% of all spinal column fractures) 50/Million/Yr (USA), 15/Million/Yr (UK) Sex 4M:1F Age Average age is 30 Yrs MISSED INJURIES 1/3 CASES OF C/SPINE INJURY ARE MISSED INITIALLY

63. Fracture Level CERVICAL SPINE 40% MOST COMMON FRACTURE IS OF C5 MOST COMMON SUBLUXATION IS C5/6 Thoracic spine (T1-T9) 15% Thoracolumbar spine (T10-L5) 30% Most common fracture is of L1 Multi level 15%

64. ASSOCIATED INJURIES • HEAD AND FACE INJURY 26 % • Major chest injury 16 % • Major abdominal injury 10% • Long bone/pelvic fracture 8%

65. Levels of Spinal Injury SKELETAL: level of bony injury NEUROLOGICAL: sensory & motor level with totally preserved function. Sensory & motor levels may be different on the same as well as on the opposite sides hence 4 levels) LEVEL OF PARTIAL PRESERVATION: presence of partial function below the neurological level,e.g sacral sparing.

66. Other systems CHEST Hypoventilation Intercostals T1-T12 Diaphragm C3-C5 Paradoxical breathing ABDOMEN Inability to perceive pain may mask features of acute abdomen Reliance on indirect features like referred pain in shoulders or investigations like DPL, USG, CT and MRI

67. C/ spine x-rays – lat view Identify Occipital condyles All seven cervical vertebrae Superior aspect of body of T1 Anatomic assessment Alignment – 5 lordotic curves Bones – contour Cartilage – discs and facet joints Soft tissues – pre-vertebral and inter-spinous space, ADI OC T1

68. Open Mouth & AP Views Occipital condyle Lat mass C1 Lat mass C2 Odontoid Peg Bifid spinous process Unco-vertebral joint C7 T1

69. Other investigations CT SCAN Indications To define a suspicious fracture on x-rays Inability to see lower cervical spine MRI Indications Neurological deficit Facet dislocations

70. Classification of Spinal Injuries Spinal Column Injuries Stable Unstable Spinal Cord Injuries Complete Incomplete SCIWORA

71. Management of spinal injuries Stable injuries Symptomatic. Bed rest. Splinting. Mobilisation Unstable injuries without neurological deficit Adequate immobilisation. Cervical spine (hard collar, sand bags, tape). Thoracolumbar spine (spinal board). Logroll. Spinal lift Dislocations and fracture dislocation should be reduced as soon as possible Closed reduction. Cervical spine (Halo traction, Gardner Wells tongs). Thoracolumbar spine (postural) ORIF Beware of disc prolapse in dislocations. MRI/ anterior approach Unstable injuries with neurological deficit Adequate Immobilisation Decompression High-dose steroids MSP start in first 8 hrs only. 30mg/kg in 15min. Wait for 45 min. 5.4mg/kg/hr/23hrs Establish as soon as possible whether injury is complete or incomplete Care of bladder, bowel, lungs and skin Haemodynamics – brady cardia/ hypotension – don’t over transfuse – atropine/inotropes

72. Medical Management of SCI Methylprednisolone (MPS) (Solumedrol) start only in the first 8 hrs of injury 30mg/kg IV in 15mins, wait for 45mins, 5.4mg/kg/hr for next 23hrs Analgesia Atropine If heart rate <50/min IV fluids and inotropes for hypotension Bladder/ Bowel/ Skin care/ Take pt off spinal board asap (max 2hrs if paralysed)

73. 1

74. 29 YEAR OLD REFRIGERATOR ENGINEER HAD BEEN OUT HORSE-RIDING, WHEN HIS HORSE HAD BOLTED AND HE WAS THROWN OFF, HITTING HIS HEAD ON THE BRANCH OF A TREE. THE PARAMEDICS HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH A RIGID CERVICAL COLLAR IN PLACE. ACCORDING TO THEM THERE WAS NO LOSS OF CONSCIOUSNESS AT ANY TIME, AND HE IS RESPONDING APPROPRIATELY TO COMMANDS. HE IS COMPLAINING OF MILD NECK PAIN AND TINGLING IN BOTH ARMS . ON GPE U FIND WEAKNESS IN BOTH ARMS, PROXIMALLY MORE THAN DISTALLY, WITH SOME ASSOCIATED LOSS OF LIGHT TOUCH AND PAIN SENSATION . WITH AN ASSISTANT MANUALLY STABILISING HIS NECK, YOU REMOVE THE COLLAR AND EXAMINE THE PATIENT. THERE IS NO BONY TENDERNESS, DEFORMITY OR DEFECT. HIS NECK IS NOT TENDER TO PALPATION .

75. Can you clear this man's cervical spine clinically?

77. SO YOU'VE SUCCESSFULLY INTERPRETED THE LATERAL FILM AS A NORMAL LATERAL CERVICAL SPINE. DO YOU HAVE ENOUGH PLAIN FILMS OR ARE YOU GOING TO TROUBLE THE RADIOGRAPHER FOR MORE VIEWS?

79. AP and Open mouth views are normal as well. What next?

80. YOU SEND THE PT OFF FOR AN MRI SCAN AND YOU GET THE RESULTS BACK - A CENTRAL CORD HAEMATOMA - CONSISTENT WITH THE CENTRAL CORD SYNDROME YOU FOUND ON EXAMINATION. YOU PACK THE PT OFF TO THE SPINAL UNIT WHERE, YOU LATER LEARNED, HE REGAINED FULL FUNCTION AND WAS DISCHARGED.

81. 2

82. YOUR PATIENT, JAMES COOK, A 32 YEAR OLD TRAVEL WRITER CAME OFF HIS MOTORCYCLE WHICH SKIDDED ON SOME ICE . THE PARAMEDICS HAVE HIM IMMOBILISED ON A SPINAL BOARD WITH A RIGID CERVICAL COLLAR IN PLACE. ACCORDING TO THEM THERE WAS NO LOSS OF CONSCIOUSNESS AT ANY TIME , AND HE IS RESPONDING APPROPRIATELY TO COMMANDS. HE IS NOT COMPLAINING OF ANY NECK PAIN . ON GENERAL EXAMINATION YOU FIND NO NEUROLOGY AND NO EVIDENCE OF OTHER INJUR Y . WITH AN ASSISTANT MANUALLY STABILISING HIS NECK, YOU REMOVE THE COLLAR AND EXAMINE THE PATIENT. THERE IS NO BONY TENDERNESS, DEFORMITY OR DEFECT. THINK YOU CAN HANDLE THIS ONE?

83. YOU REMOVE MR. COOK'S SPINAL IMMOBILISATION AND HARD COLLAR. HE LOOKS BETTER ALREADY! YOU RE-EXAMINE HIM OUT OF HIS COLLAR, AND FIND NO NEW SIGNS. HE HAS FULL AND PAIN FREE RANGE OF MOVEMENTS. YOU DISCHARGE MR. COOK WITH ADVICE TO CHANGE HIS MOTORCYCLE FOR A BUS PASS, AND TO 'STAY OUT OF TROUBLE' .

84. 3

85. YOUR PATIENT IS MR. HORATIO NELSON, A SURPRISINGLY SHORT 19 YEAR OLD, WHO HAS FALLEN OUT OF A SINGLE STOREY WINDOW WHILE AT A PARTY. HIS MATE ASSURES YOU THAT APART FROM QUITE A LOT OF ALCOHOL HORATIO ONLY TOOK 2 OR 3 ECSTASY TABLETS (THOUGH HORATIO LOOKS BLOODY MISERABLE AT THE MOMENT). SPINAL IMMOBILISATION AND A RIGID CERVICAL COLLAR ARE IN PLACE. ON EXAMINATION YOU ONLY FIND SOME BRUISING AROUND ONE EYE AND A BROKEN HUMERUS . HIS NECK IS CLINICALLY NOT TENDER, WITH NO DEFORMITY OR DEFECT, AND HE HAS NO OBVIOUS NEUROLOGY . Can you clear this man's cervical spine clinically?

87. YOU PASSEDA MR. NELSON'S LATERAL CERVICAL SPINE AS NORMAL. ARE YOU GOING TO DISCHARGE HIM?

88. YOU ORDER THE OPEN MOUTH AND AP FILMS FOR HORATIO, WHO IS NOW REALLY GETTING A LITTLE BIT MUCH. HE'S NOW OFFERING TO SINK BATTLESHIPS AND MOVE WHOLE ARMIES FOR YOU. HIS OTHER X-RAYS ARE ALSO NORMAL. YOU REMOVE HIS HARD COLLAR AND EXAMINE HIS NECK GENTLY. HE COMPLAINS OF NO PAIN OR TENDERNESS.

89. What are your plans?

90. YOU RECOGNISE THAT YOUR PHYSICAL EXAM, WHILE REASSURING, IS NOT RELIABLE GIVEN THE COCKTAIL OF DRUGS AND ALCOHOL HE HAS TAKEN. SO YOU ADMIT HIM. BY MORNING HE HAS SOBERED UP AND PREDICTABLY HE LOOKS TERRIBLE. HIS PHYSICAL EXAMINATION IS ENTIRELY NORMAL AND YOU DISCHARGE HIM INTO HARDY'S CARE WITH ADVICE.

91. 4

92. MR. CHARLES DARWIN IS A 42 YEAR OLD WHOSE CAR VEERED OFF THE ROAD. HE WAS UNCONSCIOUS ON SCENE AND REQUIRED EXTRACTION FROM THE VEHICLE . ACCORDING TO THE PARAMEDICS HE WAS HAEMODYNAMICALLY STABLE THROUGHOUT, WITH A GLASGOW COMA SCORE OF 6 INITIALLY . BOTH PUPILS ARE EQUAL AND REACTIVE . THEY INTUBATED HIM ON SCENE . HIS ONLY EXTERNAL INJURIES APPEAR TO BE BRUISING AND CUTS TO HIS FOREHEAD . SPINAL IMMOBILISATION IS IN PLACE.

93. YOU WISELY DECIDE THAT MR. DARWIN NEEDS HIS COLLAR AT THE MOMENT. EXAMINING HIM YOU CONFIRM THE PARAMEDICS FINDINGS. HE IS INTUBATED AND VENTILATED, HAEMODYNAMICALLY STABLE WITH A GCS NOW OF 4 AND EQUAL, REACTIVE PUPILS. YOU NEED TO MOVE QUICKLY AS HE MAY HAVE AN EVOLVING BRAIN INJURY. YOU ORDER A LATERAL CERVICAL SPINE FILM.

97. MR. DARWIN REMAINS STABLE BOTH HAEMODYNAMICALLY AND NEUROLOGICALLY WHILE YOU FINISH YOUR INITIAL ASSESSMENT AND RESUSCITATION. APART FROM HIS HEAD INJURY YOU FIND NOTHING ELSE. HIS OTHER CERVICAL SPINE X-RAYS ARE ALSO NORMAL. CHEST AND PELVIC X-RAYS ALSO NORMAL AND ABDOMINAL ULTRASOUND DID NOT SHOW ANY FREE INTRAPERITONEAL FLUID.

98. What's your plan?

99. MR. DARWIN COMES BACK FROM CT WITH A HEAD SCAN SHOWING MODERATE DIFFUSE AXONAL INJURY AND A SMALL SUBDURAL THAT WILL NEED SURGERY. CT OF HIS ATLANTO-OCCIPTAL REGION REVEALED AN ODONTOID PEG FRACTURE.

100. You send Mr. Darwin up to theatre for his craniotomy, and arrange for his admission to the intensive care unit. The spinal surgeons can decide whether they want an MRI or not in this case, it's not going to add much to his immediate management.

101. QUESTIONS?

102. Spinal Trauma Summary Immobilise until injury is excluded Initial management is ABC Thorough neurological examination